Neurobehavioral Rehabilitation Strategies for High-Functioning …€¦ · · 2012-09-06Neurobehavioral Rehabilitation Strategies for High- ... Neurobehavioral Rehabilitation Strategies

Neurobehavioral Rehabilitation Strategies for High-Functioning Clients

Leonard N. Matheson, PhD



EpicRehab

St. Charles, Missouri

www.epicrehab.com

Faculty Disclosure

•None•None•Owner•EpicRehab, LLCMatheson

Unlabeled Product Usage

What Was ReceivedNature of AffiliationName of

OrganizationLast Name

In accordance with the ACCME Standards for Commercial Support, course directors, planning committees, faculty and all others in control of the educational content of the CME activity must disclose all relevant financial relationships with any commercial interest that they or their spouse/partner may have had within the past 12 months. If an individual refuses to disclose relevant financial relationships, they will be disqualified from being a part of the planning and implementation of this CME activity. Employees of a commercial interest with business lines or products relating to the content of the CME activity will not participate in the planning or any accredited portion of the conference.

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Disclaimer

Dr. Matheson is the co-owner of EpicRehab LLC, a developer and manufacturer of processes and equipment used in occupational rehabilitation.

He is licensed by the Washington University School of Medicine to make available occupational rehabilitation materials developed by him and his

colleagues prior to his retirement from the University.

Neurobehavioral Rehabilitation

A holistic client-centered reality-based program using just-right challenges to return

the person with ABI to full participation, measured by feasibility for competitive employment as the primary outcome.

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High-Functioning Clients

• Above-average pre-injury IQ, often preserved post-ABI.

• Job demanded >90% of pre-injury ability.

• Usually highly competitive job x worker fit.

• Post-injury shortfall is modest and would not impede RTW for mid-level or low-level clients, but does impede RTW due to highly competitive expectations.

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Just-Right Challenge

The job demand that exists within the client’s capacity, immediately beyond the

client’s current ability.

The focus of growth-producing intervention.

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Rolewith Rules,

Demands and Rewards

Environmentwith

Affordances and Threats

Challenges

Personwith Physical and

PsychologicalCapacities

Abilities

Occupational Competence

Effectancies

OccupationalDevelopment in

Pursuit of Role-Focused

Challenges

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Normal Job Challenge

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Just-Right Job Challenge

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Feasibility for Competitive Employment

The acceptability to a competitive employer of the client’s work behaviors, in terms of:

Productivity

Safety

Interpersonal Behavior

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Evaluee: Date:

Evaluator:

Score

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FEC Factor Definition

Not

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Ind

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Min

Ass

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Mod

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Not

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Hig

h

Mod

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Low

Unc

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in

1 Quantity of Productivity Amount of dependable work output.

2 Quality of Productivity Quality of dependable work output.

3 Attendance Reporting to work on assigned days.

4 Workplace ToleranceRemaining in the workplace for the assigned

duration.

5 TimelinessReporting to work and returning from breaks on

time.

6 Work Task InstructabilityAbility to perceive and understand work

instructions.

7 Work Task MemoryAbility to remember instructions, procedures, and

rules.

8Follow Through with Accepted

DirectionsAbility to initiate and follow through on a task

until completion.

9 Concentration Ability to focus attention on assigned tasks.

10 Adherence to Safety Rules Adherence to workplace safety rules.

11 Use of Proper Body Mechanics Use of appropriate work postures and movements.

12 Workplace Safety: AuditionAbility to perceive, understand and respond to

auditory safety signals.

13 Workplace Safety: VisionAbility to perceive, understand and respond to

visual safety signals.

14 Workplace Safety: SensationAbility to perceive, understand and respond to

tactile safety signals.

15 Workplace Safety: BalanceAbility to manage balance challenges and avoid

falls.

16 Use of Protective BehaviorAbility to protect self and other workers from

danger.

17Accept Direction from a

SupervisorAbility to accept direction &/or correction from a

supervisor.

18Adjust to Different Supervisors

or Supervisory StylesAbility to maintain performance under different

supervisors.

19 Response to Fellow WorkersAbility to work with others addressing the same

task.

20 Response to Consumers Ability to communicate with consumers.

21 Response to ChangeAbility to adjust to changes &/or distractions in

work routine.

22 Follows Dress Code Acceptable attire for the workplace.

23 General Worker AttitudeDemonstrates motivation and dedication to worker

role.

Sec

tion

Tw

o -

Saf

ety

Sect

ion

Th

ree

- In

terp

erso

nal B

ehav

ior

Sect

ion

One

- P

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Present Feasibility for Competitive

Employment

Potential for Improvement

Environment & Occupation:

Feasibility Evaluation Checklist

Why do people rehabilitate?

Development of Occupational Competence:

Occupational and Environmental demands challenge the Person and stimulate growth.

Supported by self-efficacy theory and models of occupational competence, neurogenesis, and neuralplasticity.

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Rolewith Rules,

Demands and Rewards

Environmentwith

Affordances and Threats

Challenges

Personwith Physical and

PsychologicalCapacities

Abilities

Occupational Competence

Effectancies

OccupationalDevelopment in

Pursuit of Role-Focused

Challenges

Person as Worker

• The individual’s sense of competence: – Ability to respond adequately to

occupational and environmental challenges.

• Many people recover abilities with ADL, IADL, and even work skills but do not successfully return to work or remain in the workforce.

– Self-Confidence / Self-Efficacy• Many people are discouraged and confused

about whether they can handle the demands of work and the workplace.

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Environment as Workplace

• The physical, social, cognitive and emotional demands of the workplace.– Employee-to-Employer and Employee-to-

Employee behaviors, attitudes, and habits.

• Most difficult of the contexts to help the client learn to handle.– Least visible; not seen unless Person is

observed doing Occupation in Environment.

Occupation as Job

• The knowledge, skill, and ability demands of the job.– Traditional work skill development /

restoration• Focus on development or restoration of work

skills provides client with sense of “mastering the familiar”, which helps to boost self-efficacy.

– However, skill restoration outside of employer context has limited utility.

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SSA Work Disability Model

BureaucraticWork

Disability

Pathology &Diagnosis

Observedsigns &reported

symptoms

StructuralImpairment

Loss orrestrictionof person

component

FunctionalImpairment

Restrictionof person

componentfunction

FunctionalLimitation

Inability toperform

componentactions &

tasks

VocationalNon-

Feasibility

Inability toperform

fundamentalwork

behaviors

OccupationalDisability

Inability toperformspecific

workbehaviors

Track A

Track B

Track C

Executive Dysfunction

1. Inhibitory Control2. Mental Flexibility3. Emotional Control4. Self-Monitor5. Initiate6. Working Memory7. Planning & Organization8.Task Monitoring9.Organization of Materials

For Persons with ABI

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Work-Oriented Tests

• Personnel Test for Industry Oral Directions Test

• Employee Aptitude Survey Battery

• Wonderlic Personnel Test

• Watson Glaser Critical Thinking Appraisal

• Career Assessment Inventory

• Norm-referenced to employee groups.

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Personnel Test for IndustryOral Directions Test

• Paper & pencil test of ability to follow oral directions.

• Very useful screening tool for persons whose brain injury affects cognition.

• Sometimes frustrating experience for client.

• Monologue is read from script.

• 39 items, 15 minutes.

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Wonderlic Personnel Test

• Math, language, reasoning.

• Most highly researched pre-placement screening test in the U.S.

• Compare client’s abilities to the abilities of people in hundreds of occupations.

• 50 items, timed 12 minutes.

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Employee Aptitude Survey

• 10 sub-tests.

• Most highly researched aptitude battery.

• Compare client’s aptitudes to the aptitudes of people in dozens of occupations.

• 9 sub-tests are timed 5 minutes/each.

• 1 sub-test timed 10 minutes.

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Watson Glaser Critical Thinking Appraisal

• “Critical Thinking” = Ability to: – Define a problem.

– Select pertinent information.

– Recognize stated and unstated assumptions.

– Formulate relevant hypotheses.

– Draw valid conclusions.

• White collar, technical, professional.

• 80 items, timed 40 minutes

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Career Assessment Inventory

• Compares interests of the client in terms of Holland Occupational Types system.

• Two different levels, one for persons with high school or less education and the other for persons with college education.

• Compares client’s interests for thousands of occupations.

• 305 or 370 items, untimed, approx. 45 minutes.

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Environment & Job Analysis Tools

• O*NET

• D.O.T.

• Fleishman Job Analysis Survey

• Job description from employer

• Job description interview with worker

• Worksite visit

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Occupation Measurement Tools

• One-off work simulations.

• Structured work simulations, Valpar, etc

• Structured work activity groups (SWAGs)

• PODs available soon.

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Work Simulation

• Work simulation is the primary method to assess vocational feasibility:– Job Analysis or Job Description

– Task Analysis

– Select available work samples.

– Design new work samples of essential functions.

– Screen the client for safety.

– Administer work samples.

– Record performance data.

– Interpret findings & report results.

Work Simulation Practice Hierarchy

SafetyReliabilityValidity

PracticalityUtility

However, designing simulations to adhere to these standards is burdensome.

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Logistical Quagmire

• Because we must adhere to the Hierarchy, “one-off”simulations can be very problematic.– Safety criteria violations can lead to injury and liability.

– Reliability and validity criteria violations will cause challenges to credibility of results and acceptability of our opinions.

– Practicality criteria violations will lead to unacceptable expense and time investment.

SWAG As An Alternative

• Developed by recognized experts at Washington University Program in Occupational Therapy.

• Adheres to formal development procedures.

• Demonstrated to be safe.

• Uses a structured and standardized approach designed to achieve reliability across time and between therapists.

• Provides information on client’s ability to work; in general and with regard to occupational skills and abilities.

• Implemented with minimal expense for equipment, supplies and time.

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SWAG: Hallmarks

• Each SWAG is a suite of related work activities centered on a “real world” theme that is housed within a virtual business.

• Each activity is composed of tasks that are graded in terms of work demand.

• Work skills are less important than “employee behavior”.

• Employee behavior is frequently evaluated.

Return to Work Evaluation

• Feasibility for competitive employment.– Use the Feasibility Evaluation Checklist to identify

underlying work behaviors and attitudes.• Feasibility Evaluation Checklist

– Observation

– Self-Report

• FEC Examiner’s Manual

• Job match based on job analysis or task analysis of job description.

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“Constructive Failure” Philosophy

• Crucial to the client’s development.

• Usually occurs during work simulation, but can also occur during standardized testing.

• Based on a meaningful challenge, during which the client’s performance falls short of a competitive employment standard.

• Handled by therapist to integrate and use for future planning.

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“Constructive Failure” Examples

• Arriving late to OPC appointment, if handled like employee - employer, not client - therapist.

• Breaking down with frustration during Oral Directions Test.

• Making an unacceptable number of errors on a SWAG activity.

• Not following SWAG safety rules.

• Not getting along with fellow workers on SWAG interactive activity.

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Case Example: Maude

• 32 year-old female registered nurse.• mTBI due to auto accident eight months prior.• Reported functional limitations:

– Cognitive endurance vs. Physical endurance?– Working memory?– Ability to multi-task?

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OPC Intake

• Lacked confidence in abilities.• Stopped going to work “before I got fired”.• Used O*NET Ability Questionnaire to identify

occupation-relevant shortfalls.• Refer to OAQ handout.

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O*NET Occupational Information System

Worker Requirements

Worker Characteristics

Occupation-Specific

Requirements

Occupational Requirements

Occupation Characteristics

Experience Requirements

O*NET

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O*NET Ability Questionnaire

• High-functioning clients complete self-description in terms of O*NET Abilities importance.

• Therapist uses information to identify key job demands and set just-right challenge.

• Available free at:– http://www.epicrehab.com/swag/

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Initial Analysis

• Professional Opinion:– Job involves high level physical, perceptual &

cognitive skills.

– At or near performance level for prior job.

– Lacks self-confidence.

– Cognitive endurance is primary limiting factor.

• Maude’s Opinion:– Not near levels needed to return to work.

– Should not have tried to return to work; “Almost blew it and lost my registration!”

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OPC Goals

• LTG: Return to previous job with modified duties.• STG:

– Accurately identify strengths & weakness for work.– Attend to work tasks 1 hour without redirection.– Perform all assigned work tasks with 98% accuracy.– Meet all deadlines.– Use compensatory strategies for memory loss.– Accurately state accommodations for return to work.– Demonstrate safe compensatory strategies for

endurance deficits.

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OT Contact with Employer

• Job descriptions for all positions.

• Prior work performance.

• Options for modified duties upon RTW.

• Job specific tasks identified for simulations

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Work-Related Assessments

• Personnel Test for Industry ODT– 90th percentile

• Wonderlic Personnel Test– 62nd percentile for college grads, above minimum

suggested maintenance score.

• Watson-Glaser CTA– 70th percentile for registered nurses.

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Physical Demand Level

Occasional0-33% of the workday

Frequent34%-66% of the workday

Constant67%-100% of the workday

Typical Energy Required

Below Sedentary Less than 10 lbs Unable Unable Less than 1.5 METS

Sedentary 10 lbs Negligible Negligible 1.5 - 2.1 METS

Light 20 lbs10 lbs

and/or walk/stand/push/pullof arm /leg controls

Negligibleand/or

push/pull of arm/legcontrols while seated

2.2 - 3.5 METS

Medium 20 to 50 lbs 10 to 25 lbs 10 lbs 3.6 - 6.3 METS

Heavy 50 to 100 lbs 25 to 50 lbs 10 to 20 lbs 6.4 - 7.5 METS

Very Heavy Over 100 lbs Over 50 lbs Over 20 lbs Over 7.5 METS

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OPC Strengthening Exercise

• Stand on a stable surface, with plenty of room.

• With a 5-lb. potato bag in each hand, extend arms straight out from your sides and hold as long as you can. Try to reach a full minute.

• After a couple of weeks, move up to 10-lb potato bags.

• Try 50-lb potato bags and then eventually try to get to where you can lift a 100-lb potato bag in each hand, still holding your arms straight for more than a full minute.

• After you feel confident at this level, put a potato in each bag.

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SWAG 1 Telephone Answering

• Just-right challenge began with mid-level and progressed to highest level over two weeks.

• After highest level achieved, multi-tasking with Doll Chair Assembly was undertaken.

• Initially, she could not switch attention fast enough, but worked with OT to develop strategies to improve to competitive standard.

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SWAG 1 Mailing List Maintenance

• Good attention to detail, with 95% accuracy on first trial.

• Used with Conference Room Scheduling for just-right challenge.

• Required three sessions to develop strategies to handle both tasks simultaneously.

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SWAG 1 Incidental Learning

• Quiz after phone messages to assess incidental learning.

• Client scored 55% on this quiz.

• Discussed memory after this quiz.

• Identified compensatory strategies for memory.

• Re-test after re-trial two weeks later found 85% accuracy, significantly boosting confidence in strategies.

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SSA Work Disability Model

BureaucraticWork

Disability

Pathology &Diagnosis

Observedsigns &reported

symptoms

StructuralImpairment

Loss orrestrictionof person

component

FunctionalImpairment

Restrictionof person

componentfunction

FunctionalLimitation

Inability toperform

componentactions &

tasks

VocationalNon-

Feasibility

Inability toperform

fundamentalwork

behaviors

OccupationalDisability

Inability toperformspecific

workbehaviors

Track A

Track B

Track C

Executive Dysfunction

1. Inhibitory Control2. Mental Flexibility3. Emotional Control4. Self-Monitor5. Initiate6. Working Memory7. Planning & Organization8.Task Monitoring9.Organization of Materials

For Persons with ABI

Executive Functions & Cognitive Components

Cognitive Component

#1

Cognitive Component

#2

Cognitive Component

#3

Cognitive Component

#4

Cognitive Component

#5

Cognitive Component

#6

Cognitive Component

#7

Cognitive Component

#8

© LN Matheson, PhD

Sel

f-M

onito

rT

ask-Monitor

Planning & Organization

Initiate

Working Memory

Organization of Materials

Mental Flexibility

Emotional Control

Inhibitory Control

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Neurocognitive vs. Neurobehavioral

• Neurocognitive function is usually measured by neuropsychologists and speech / language therapists.

• Neurobehavioral function is usually measured by occupational therapists and vocational evaluators.

• Both are necessary to consider in return to work planning.

Triage with BRIEF

• BRIEF is a good general neurobehavioral questionnaire:– Self-Rating

– Informant Rating

• Two Indices:– Behavioral Regulation Index

– Metacognition Index

• Age-based normative data

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SWAG Development Project

Original

Washington University School of Medicine

SWAG 1 Materials

Available Free:

www.epicrehab.com

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Documents

Neurobehavioral Rehabilitation Strategies for High-Functioning …€¦ · · 2012-09-06Neurobehavioral Rehabilitation Strategies for High- ... Neurobehavioral Rehabilitation Strategies